Acute Myocardial Infarction Triggered by Coronary Artery Dissection and Heparin-Induced Thrombocytopenia: A Case Report

Nikath Nasreen N ¹, Kaavya M ¹, Logeswari B M ¹, Blessy John ^1*

This case showed the need for awareness of rare myocardial infarction causes, such as coronary artery dissection and heparin-induced thrombocytopenia, highlighting complex diagnostic and management challenges.

Abstract

Background: Myocardial infarction (MI) is typically associated with atherosclerosis, but rare etiologies like coronary artery dissection and heparin-induced thrombocytopenia (HIT) can also provoke MI. The simultaneous occurrence of these two conditions is exceedingly rare. This report presents the case of a 69-year-old woman who sustained blunt chest trauma from a motor vehicle accident and later developed MI due to both coronary artery dissection and HIT. Methods: The patient initially presented with chest trauma but was discharged after symptom resolution. Subsequently, she was re-admitted for unrelated symptoms and was administered subcutaneous heparin, leading to significant thrombocytopenia. Shortly after discharge, she presented with acute MI. Coronary angiography identified a spiral dissection with thrombosis in the right coronary artery, and laboratory tests confirmed HIT. Results: The patient underwent catheter-based thrombectomy and was treated with a direct thrombin inhibitor, followed by systemic anticoagulation with warfarin for three months. The patient recovered without further complications. Conclusion: This case represents the first documented instance of MI due to the combined effects of coronary artery dissection and HIT. It underscores the need for heightened awareness and prompt intervention in atypical MI presentations, especially in the context of recent trauma and heparin exposure. Multidisciplinary management was crucial in achieving a favorable outcome.

Keywords: myocardial infarction, coronary artery dissection, heparin-induced thrombocytopenia.

References

Allam, A. H., Thompson, R. C., Wann, L. S., Miyamoto, M. I., Nur El-Din, A. E.-H., El-Maksoud, G. A., Al-Tohamy Soliman, M., Badr, I., El-Rahman Amer, H. A., Sutherland, M. L., Sutherland, J. D., & Thomas, G. S. (2011). Atherosclerosis in ancient Egyptian mummies: the Horus study. JACC Cardiovasc Imaging, 4(3), 315–327. https://doi.org/10.1016/j.jcmg.2011.02.002

Benjamin, E. J., Muntner, P., Alonso, A., et al. (2019). Heart disease and stroke statistics—2019 update: a report from the American Heart Association. Circulation, 139(10), e56–e528. https://doi.org/10.1161/CIR.0000000000000659

Biroschak, B. J., & Buckley, J. (2020). Coronary artery dissection and occlusion due to sports injury. Circulation, 103(8), 1174-1175. https://doi.org/10.1161/01.CIR.103.8.1174

Cardenas, G. A., Grines, C. L., Sheldon, M., & Goldstein, J. A. (2008). Spontaneous coronary artery dissection. Southern Medical Journal, 101(4), 442-446. https://doi.org/10.1097/SMJ.0b013e318167b819

Chong, B. H., et al. (2015). Heparin-induced thrombocytopenia. Mayo Clinic Proceedings, 90(12), 1625-1632. https://doi.org/10.1016/j.mayocp.2015.08.012

Fernández-Friera, L., Peñalvo, J. L., Fernández-Ortiz, A., et al. (2015). Prevalence, vascular distribution, and multiterritorial extent of subclinical atherosclerosis in a middle-aged cohort. Circulation, 131(24), 2104–2113. https://doi.org/10.1161/CIRCULATIONAHA.114.014310

Guo, H., Chi, J., Yuan, M., & Qiu, Y. (2011). Acute myocardial infarction caused by blunt chest trauma: a case report. International Journal of Cardiology, 149(2), e80-e81. https://doi.org/10.1016/j.ijcard.2009.04.009

Hazeleger, R., van der Wieken, R., Slagboom, T., & Landsaat, P. (2001). Coronary dissection and occlusion due to sports injury. Circulation, 103(8), 1174-1175. https://doi.org/10.1161/01.CIR.103.8.1174

Jasti, S. M., et al. (2019). Heparin-induced thrombocytopenia: a prothrombotic disorder. Annals of Pharmacotherapy, 53(3), 273-284. https://doi.org/10.1177/1060028018800137

Lu, H., & Daugherty, A. (2015). Atherosclerosis. Arteriosclerosis, Thrombosis, and Vascular Biology, 35(3), 485–491. https://doi.org/10.1161/ATVBAHA.115.305380

Moroni, F., Ammirati, E., Norata, G. D., Magnoni, M., & Camici, P. G. (2019). The role of monocytes and macrophages in human atherosclerosis, plaque neoangiogenesis, and atherothrombosis. Mediators of Inflammation, 2019, 7434376. https://doi.org/10.1155/2019/7434376

Pishko, S. J., & Cuker, A. (2018). Heparin-induced thrombocytopenia: clinical diagnosis and management. Current Hematologic Malignancy Reports, 13(3), 140-147. https://doi.org/10.1007/s11899-018-0457-7

Przybojewski, J. (2017). Less common etiologies of myocardial infarction. International Journal of Cardiology, 232, 350–353. https://doi.org/10.1016/j.ijcard.2017.02.027

Verma, A., et al. (2022). Acute myocardial infarction due to blunt chest trauma. Journal of Cardiovascular Medicine, 23(8), 318-320. https://doi.org/10.24589/jcm.2022.318

Yadav, R., et al. (2017). Atypical etiologies of myocardial infarction. Heart, Lung and Circulation, 26(9), 865-872. https://doi.org/10.1016/j.hlc.2017.01.018